The Right Ventricle During the Acute Respiratory Distress Syndrome Revisited by Echocardiography

We illustrate the valuable information provided by echocardiography for hemodynamic monitoring and for optimizing ventilatory strategies, during ARDS. Although the transthoracic and the transesophageal routes can be used, we always prefer, in the absence of contraindications, to perform transesophageal echocardiography. ARDS includes numerous affections which brutally damage the interface between the distal airway tract and pulmonary vascular bed. Two factors combine to produce right ventricular systolic overload, the pathologic features of the syndrome per se and mechanical ventilation. Acute cor pulmonale (ACP) reflects the severity of the pulmonary disease, but may also be caused or exacerbated by an aggressive and unsuitable ventilatory strategy. With tidal volume limitation, the incidence of ACP has declined to 25%. Providing that ventilatory management is adapted to right ventricular function, ACP is no longer significantly associated with increased mortality. If not, it is demonstrated that right ventricular dysfunction is actually associated with a poor prognosis. In conclusion, whereas some have promoted a lung protective approach, echocardiography allows us to promote a right ventricular protective approach, by adapting respiratory settings to right ventricular function, which is key in the prognosis of these patients.